Breech presentation Flashcards
1
Q
Etiology
A
- Something filling the lower segment->placenta preaevia or fibroids
- Extension of the legs can prevent flexion of trunk and further rotation
- +ratio of amniotic fluid to fetal size= allowing +fetal movement
- Multiples->fetuses restricting the movement of the other
- Fetal malformation may prevent cephalic presentations
2
Q
Risk factors
A
- Nulliparity
- Female
- SGA, preterm
- Maternal uterine abnormality
- Female congenital abnormality
3
Q
Types
A
- Both knees extended= frank breech, most common
- Both knees flexed= flexed breech, complete
- One knee flexed, one extended= incomplete breech
- Hips extended= single or double footling->very small babies
4
Q
Diagnosis
A
- Abdominal palpation-> no head palpable in lower, ballotable in upper
- Vaginal confirms no head in pelvis, identify position of fetal sacrum, station of breech. Exclude cord prolapse and nuchal cord.
- Investigations->USS
5
Q
Risks of breech
A
- 2-3 X mortality (preterm)
- Hypoxia rarely->cord prolapse and slow delivery of head
- Maternal->PE, infection, bleeding, damage to bladder and bowel, slow recovery from delivery
6
Q
Management pre-labour
A
- From 37 weeks can attempt external cephalic versio
- Plan delivery before 41 weeks
- CT scan standing lateral + USS to determine size if not reverting
- If any complications ?C section at 38-39 weeks
7
Q
Process of external cephalic version, contraindications, if Rh-ve, if succes/no success
A
- ECV + tocolytic
- Listen to fetal heart before and after
- Contraindications
Uterine scar from previous C section
HTN in other
Ruptured membranes
Planned c section anyway
Multiples
APH - If Rh-ve give anti-D
- If successful->monitor weekly to ensure remains in cephalic position
- If unsuccuessful->cousel re route of delivery, breech vaginal vs caesarean.
8
Q
Reasons for unsuccessful ECV
A
- Breech too engaged
- Uterus/abdominal wall too tense
- Fetal abnormal, twins
- Do USS
9
Q
Management during labour: first, second, third
A
- First stage
+risk of premature
rupture of membrane
Vaginal examination to exclude cord prolpase
Epidural–> allows analgesia and option for operative Mx if
required - Second stage
Pelvis manouvre->Lovsett
Mariceau Smellie Veit manouvre
Propped up dorsal position, bed needs to be able to allow lithotomy
Need experienced Obs/Anesthetist/Pediatrician
Arms normally crossed on chest
Legs delivered–> hand down, then occiput–> hands in mouth, forceps?
Delivered face to perineum
Mouth/nose cleared of mucus
At time of crowning->?episiotomy - Third stage
Placenta delivered normally
Syntometrine given when delivery of head as +risk of PPH
10
Q
Counselling about breech risks
A
- Due to no moulding, unable to determine if baby’s head is too big
- 1 in 20 risk of neonatal death during vaginal birth
- Cord prolapse also more common
- Term breech trial in Lancet 2000 showed 3 X mortality/morbidity with breech
- Most will be born safely, many will die/brain damage.
- If home birth, worse outcomes.
- If >4000g ++risk
- If primi, Xreassurance that she has delivered baby
- Options are C section or ECV
- 40% chance of reverting to cephalic with ECV, small risk to baby and cord->may need C section
- Possible will change position any time up until labour, less likely if frank breech.
11
Q
Explaining ECV
A
- Should be performed at 36-37 weeks
- Before this baby may turn spontaneously
- Perform where facilities available for emergency C section
- ContraI are: APH, HTN, uterine scar, multiples
- Monitor fetus before and after
- Tocolytic 30 mins before procedure
- Direct damage to baby, cord entanglement and placental abruption
- Gently dislodging buttocks from mother’s pelvis and somersaulting into cephalic position
- Rh -ve mothers should be given anti-D
12
Q
Why is my baby in breech
A
- Something obstructing lower segment
- Uterine abnormalities
- Some babies prefer position
- +amniotic fluid
- SGA
13
Q
Brief explanation and booking of C section
A
- Booked at 39 weeks, to avoid emergency if goes into labour
- Regional anaesthesia
- Will remain awake
- One support person in the room
- Can usually go home after 24 hours if well
- 60-70% chance of VBAC in next pregnancy
- Explain risks of procedure (2 in 10 000 risk of death)
- Consent form
- Bloods->FBC, G&H
- Anesthetic review
- Book in theatre
14
Q
Management of mastitis
A
- Can continue breastfeeding
- Diflucloxacillin 10 days
- Panadeine forte
- Heat packs
- Follow up
15
Q
Cause of postpartum pyrexia
A
- Urinary tract infection
- Endometritis
- Wound infection
- Basal atelectasis and pneumonia
- Mastitis
- DVT
- Incidental->another non-post partum related cause